NATIONAL KIDNEY AND TRANSPLANT INSTITUTE Nursing Services Department

Institute of Advanced Nursing and Allied Health Professions

In Partial Fulfilment of the Requirements of the 33 Post-Graduate Course in Clinical Nursing Practice
rd

Nursing Management of a Patient with Uncontrolled Diabetes Mellitus Stage II focused on Pathophysiology

Presented by: Patricia Marie R. Jimenez, RN WARD 3D

Presented to: Mercedita J. Vargas-Jocson, RN, CRN Merika D. Jimenez, RN Rancy Robin T. Celeste, RN

April 2010

TABLE OF CONTENTS

Introduction Objectives Health Assessment I. II. III. IV. Clients Profile Current Health Status Gordons Functional Health Status Physical Assessment

1 2

3 4 7 8 11 13 14 15 16

Anatomy and Physiology Pathophysiology Conclusion Bibliography Appendix A

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INTRODUCTION
Diabetes is the disorder of carbohydrate, protein and fat metabolism resulting to a imbalance between insulin availability and insulin need. It can represent an absolute insulin deficiency, impaired release of insulin by the pancreatic beta cells, inadequate or defective insulin receptors, or the production of inactive insulin or insulin that is destroyed before it can carry out its action. A person with uncontrolled diabetes is unable to transport glucose into fat and muscle cells; as a result, the body cells are starves, and the breakdown of fat and protein is increased. In type 2 diabetes (formerly called non-insulindependent diabetes or adult-onset diabetes), the pancreas continues to produce insulin, sometimes even at higher-than-normal levels. However, the body develops resistance to the effects of insulin, so there is not enough insulin to meet the body's needs. Diabetes is widely recognized as one of the leading causes of death and disability in the United States. In 2006, it was the seventh leading cause of death. However, diabetes is likely to be underreported as the underlying cause of death on death certificates. In 2004, among people ages 65 years or older, heart disease was noted on 68 percent of diabetes-related death certificates; stroke was noted on 16 percent of diabetes-related death certificates for the same age group.It is estimated that nearly 150 million people worldwide suffer from diabetes, and the number is expected to rise to 300 million people in the next 20 years. Local statistics show that over two million Filipinos are afflicted with diabetes. Complications commonly associated with uncontrolled or poorly controlled diabetes include heart disease, stroke, kidney failure and blindness. Foot problems are common among people with diabetes and may become severe enough to cause ulceration and infection, eventually resulting to amputation. Foot problems have been reported as the most common complication leading to hospitalization among people with diabetes. Two to three% of all patients with diabetes develop foot ulcers every year, and approximately 15% develop foot ulcers during their lifetime. In a controlled study of 854 outpatients with diabetes followed up in a general medical clinic, foot problems accounted for 16% of hospital admissions during a 2 year period and 23% of total hospital days. 1 In people with diabetes, lesions of the feet represent the effects of neuropathy and vascular insufficiency. Approximately 60% to 70% of people with diabetic foot ulcers have neuropathy without vascular disease, 15%-20% have vascular disease, and 15%-20% have neuropathy and vascular disease. I chose Diabetes Mellitus Stage II as my case because it is a very interesting case and I would like to show a relationship between the patients lifestyle, diet and lifestyle as well as her family history to the development of her diabetes. I also believe that a deeper understanding of this disease will further help me develop a focused nursing care plan to each patient with this disease. I also chose this case because as a health advocate nurses should promote health by reducing behavior induced diseases, this is done by further searching for more knowledge to prevent the development of such diseases. This paper seeks to study the case of a patient with Uncontrolled Diabetes Mellitus Type 2 with a Non-Healing wound as a complication and will focus on the nursing care plan. A nursing care plan outlines the nursing care to be provided to a patient. It is based on a nursing assessment and a nursing diagnosis, carried out by a nurse. The nursing care plan is begun when the patient is admitted to the health service, and, after the initial nursing assessment, a diagnosis is formulated and nursing orders are developed. The goal of the process is to ensure that nursing care is consistent with the patient's needs and progress toward self-care. In line with this, I have formulated 10 nursing problems and discussed 5 nursing care plans that are specific to the care and needs of my patient.

1. American diabetes Association. (2004) Preventative foot care in people with diabetes. Diabetes care 27, S63-S64

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OBJECTIVES

Trainee At the end of the Nursing Care Plan, the trainee shall have been able to: 1. Compose a holistic nursing care plan for the patient 2. Involve the patient in the management of her condition 3. Formulate patient specific nursing problems 4. Formulate patient centered nursing care plans Patient At the end of the Nursing Care Plan, the patient shall have been able to: 1. Understand the importance of complying to the management of her condition 2. Participate in the management of her condition IANAHP At the end of the Nursing Care Plan, the IANAHP shall have been able to: 1. Assess the level of knowledge of the trainee regarding the nursing care plan of her case. 2. Evaluate the competency of the trainee on how she understands the nursing care plans of her patients case.

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ASSESSMENT
I. Clients Profile Clients Name Age Date of birth Address Place of birth Sex Educational Attainment Nationality Occupation Civil Status Date Admitted Date of Discharge Attending Physician Resident Chief Complaint Admitting Diagnosis : : : : : : : : : : : : : : : : Patient PA 48 years old September 28, 1961 Manila QC Female College Graduate Filipino Housewife Married January 31, 2010 February 11, 2010 Dr. Crista-Luna/ Dr. H. Nialaga Dr. Pellobelo Namamaga ang binti ko at may sugat ako sa paa na hindi gumagaling Presence of Non-healing wound, Hypertension Stage 2, Uncontrolled DM type 2

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II. Current Health Status History of Present Illness Chief Complaint: Namamaga ang binti ko at may sugat ako sa paa na hindi gumagaling 1 year prior to admission, the patient developed a wound on the right upper side of her sole. There was numbness noted by the patient yet no ulceration and pain sensed. The patient did not seek consultation regarding her wound and decided to just put a dressing over it since she thought that it would heal by itself in time. 1 month prior to admission the patient experienced edema on both her lower extremities for a week that would not subside thus this pushed her to consult at the out patient department of NKTI. The attending physician assessed her and noticed her wound at her sole, she told the physician that has had her wound for a year. With this the physician decided to have tests done to the patient including blood analysis, Urine analysis, lipid profile and chemical analysis. 1 hour prior to admission the patient went back for a follow up consult, her physician assessed her and took her Blood Glucose, the result was high and lead to her admission for further assessment and management. Past Health History The client has not undergone any surgeries in the past. She verbalized an episode of urinary tract infection when she was 12 years old. No consultation was done and she did not take any medication. The patients sister advised her to take Metformin since she takes it as her treatment regimen for diabetes. But the patient was not able to comply with the said medication. Immunizations were given but the patient was unable to enumerate her past immunizations. The patient verbalized that she experienced episodes of fainting when she was younger but did not do anything about it. No foreign and local travel in the past. She has had 4 pregnancies but unfortunately her first pregnancy resulted to a stillbirth. Her next pregnancy was successful and was delivered as normal spontaneous delivery. Her next 2 children were normal as well. All her children has had complete immunization. Socio-Cultural Health Patient PA is a 48-year old female and is currently residing with her husband, 3 children and her youngest brother. She lives in a two-storey house inside a village with a clean environment and away from citys noises. She enjoys watching television and singing and talking to neighbors. She has been happily married to her husband for over 20 years now. She maintains a close relationship with her family and friends. She is an all around housewife and is responsible for taking care of her children and her youngest brother as well.

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Family Health History All her grandparents are already deceased and died from natural causes. In her mothers side the patient has a history of Cancer from her uncle and diabetes from her aunt. In her fathers side she has a history of hypertension from her father and grandmother. She has a brother who has mental retardation and has chronic kidney disease. Genogram

Grand mother

Grand father

Grand mother

Grand father

Mother

Father

Patient

Legend: Male Hypertension Hypertension

Female Patient Mental Retardation/ Chronic Kidney disease

Cancer of the Esophagus Diabetes Mellitus

Deceased

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III. Gordons Functional Health Pattern (2/04/10) A. Health Perception Health Management Subjective data: Ok naman ang pakiramdam ko, wala namang masakit sa akin. Ang sugat ko lang ang problema kasi isang taon na ito hindi pa gumagaling. Natatakot akong lumala ang sakit ko. Akala ko kasi dati ay simpleng sugat lang ito kaya nilagyan ko lang ito ng bandaid at hinayaan ko itong gumaling kaso isang taon na ay hindi pa din ito gumagaling at parang lumalaki pa. Nung isang taon ay nagpa-test ko ng blood sugar ko, mataas ang resulta kaya doon ko nalaman na may diabetes ako, sabi ng ate ko uminom ako ng Metformin kasi yun din ang gamot nya kasi may diabetes din sya, kaso hindi ko ito naiinom palagi. Hindi ko alam ang gagawin ko sa aking sakit. Nung isang buwan ay namaga ang mga paa ko pero hinayaan ko lang ito kaso nga lang ay isang lingo na ito at hindi pa nawawala kaya nagpakunsulta ako. Wala akong bisyo, hindi ako umiinom at naninigarilyo, hindi din ako nagdadrugs. Ang alam ko ay kumpleto ako sa bakuna kaso hindi ko na matandaan kung ano-ano ito. Matagal na din akong may hypertension kaya ako nag-gaamot para makontrol ito. As verbalized by the patient. Objective data: Presence of an over keratinized tissue about 2cmx3cm width and an ulcer of 1cmx 1cm width of granulitic tissue on the patients right foot with dressing, that is dry and intact. No pain verbalized by the patient. The patient can distinguish sharp and dull all over her body except in her right foot where she verbalized numbness on the upper part of her foot. No edema was noted. She did not engage into smoking and drinking alcoholic beverages. Patient has a heplock on her left hand, no redness and itching present. Patients mood shifted when the topic of her condition came up, she avoided eye contact and was worried. B. Nutritional Metabolic Pattern Subjective data: Malakas ako kumain, mahilis ako dati sa matataba, yun matataas sa cholesterol, kanin peanuts ganon kaya siguro palaging mataas ang aking presyon. Hindi ko kasi alam na may diabetes pa ako kaya kain lang ako ng kain. Nung isang taon nalaman ko na mataas ang aking blood sugar kaya naging maingat ako sa aking pagkain. Kaso minsan ay hindi ko din mapigilan kumain lalo na pag may handaan. Paborito ko ang mga pagkaing may fiber katulad ng otmeal para mabalilis ang pagnumi ko. 3 beses akong kumakain sa isang araw tapos nagmimirienda din ako sa hapon. Umiinom ako ng 8 na baso ng tubig sa isang araw. Dati ay lumakas akong kumain at dumami ang paginom ko, hindi ko alam kung bakit pero parang palagi akong gutom at uhaw. Ngayon kinakain ko lang ang binibigay ng dietary, hindi ko lang alam kung maipapagpatuloy ko ito pag nakauwi na kami. Wala naman akong allergy sa kahit anong pagkain. As verbalized by the patient. Objective data: Height: 55 ft, Weight: 58 kg, BMI: 22. Oral mucosa pink, no foul odor noted, gag reflex is present, gums are pinkish, moist, no swelling, no bleeding noted, teeth are without dental carries, presence of dentures in the upper and lower incisor teeth, tongue is central in position, can distinguish different tastes, uvula is at the center, symmetrical and moves upward when the patient says ah.

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C. Elimination Pattern Subjective data: Dati ay may naranasan ko yung ihi ng ihi. Akala ko ay dahil yun sa pag-inom ko ng madami kaso nalaman ko na isa pala yung sintomas ng Diabetes. Hindi naman ako hirap umihi at wala namang dugo ang aking ihi. Isa hanggang dalawang beses lang ako dumudumi sa isang araw kaso ngayon ay dumalang ang pagdumi Wala namang masakit kapag dumudumi ako at wala din namang dugo.Hindi ako mashado nakakadumi dito, hindi ko alam kung bakit pero hindi pa ako dumudumi simula ng dumating ako. As verbalized by the patient. Objective data: Bowel sound heard 3 times per quadrant in one minute, no tenderness noted. D. Activity Exercise Pattern Subjective data: Hindi ako nageexcercise sa bahay, ang pagtatrabaho ko lang sa bahay ang pinakaexcercise ko. Minsan ay naglalakadlakad ako. Nung nagkasugat ako ay hirap akong maglakad dahil iniiwasan kong malagyan ng dumi ang aking sugat minsan kapag mataas ang aking presyon ay nahihilo ako kaya nagpapahinga na lamang ako. Madali ako manghina kapag mataas ang presyon ko. Ngayon hindi ako mashado nakakalakad kasi lagi lang ako nakahiga, minsan umuupo ako pero madalas nakahiga ako. As verbalized by the patient. Objective data: Muscle strength of 4/5 on both upper and lower extremities. Patient appears weak. Good Range of motion on all upper and lower joints, no evidence of swelling or deformity, the patient can distinguish sharp from dull sensation. Biceps and triceps reflex of grade 2+. Patient has a heplock on her left hand, no redness and itching present. Knee jerk reflex of 2+. E. Sleep- Rest Pattern Subjective data: Natutulog ako ng mga 11 ng gabi at nagigising ako ng 9-10 ng umaga. Madalas kasi akong puyat dahil ang kapatid ko ay takbo ng takbo kaya sinusuway ko siya baka kasi nakakaistorbo na siya sa mga nars sa labas. Kapag gising ko naman ay nakapagpahinga ako at maaliwalas ang aking pakiramdam. Dito sa ospital ay madaling araw na kami nakakatulog kasi takbo ng takbo ang kapatid ko, naguguluhan ako at hindi ako makatulog. As verbalized by the patient. Objective data: Dark circles around the eyes were noted. F. Cognitive Sensory Perceptual Pattern Subjective data: Nakatapos ako ng College sa kursong accountancy pero pinili kong maging housewife para maalagaan ang aking mga anak.Marunong syang bumasa at sumulat. Tagalog ang gingagamit kong dialekto, marunong din akong mag-english. Hindi pa naman ako makakalimutin at hindi pa ako naguulyanin.Wala akong problema sa pandinig, mnagsasalamin ako kapag nagbabasa. As verbalized by the patient. Objective data: The patient is oriented to time, place and person, cooperative and has a good memory both recent and remote.

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G. Self-perception Pattern Subjective data: Kung irarate ko ang aking Self-Esteem ay 8. Hindi naman ako mahiyain. Ginagawa ko ang lahat na sa tingin ko ay tama at makakabuti sa aking pamilya. Takot akong lumala ang aking sakit kaya lang hindi ko alam kung ano ang gagawin ko dahil hindi ako sumusunod sa mga payo ng aking mga doktor. As verbalized by the patient. Objective data: She is able to maintain eye contact throughout the conversation. No hesitations in answering questions and gives detailed answers to questions asked. H. Coping Stress Tolerance Pattern Subjective data: Ang dahilan ng aking pagkastress ay ang aking kapatid na nagpeperitoneal dialysis, ang aking mga anak at ang pagkakaospital ko. Nasstress ako sa kapatid ko kapag may sumpong siya, takot akong lumala ang aking sakit. Namomroblema din ako sa pera paminsan pero tinutulungan naman ako ng asawa ko sa mga bagay na yon. Kapag may problema kaming mag-asawa ay pinaguusapan naming ng mabuti ang lahat ng bagay at lahat ay gingawa naming para masolusyonan ito. As verbalized by the patient. Objective data: Patient is calm, answers all questions directed to her without hesitancy, maintains eye contact at all times. I. Role Relationship Pattern Subjective data: Close kami sa mga anak ko. Madalas kaming uusap lalo na kapag may problema sila. Sa pagdedesisyon, pinaguusapan naming ng mabuti ng asawa ko ang lahat ng solusyon para makapili kami ng pinaka mabuting solusyon na makakatulong sa aming pamilya. Ngayon walang tumatao sa bahay. Nalulungkot ako at pakiramdam ko ay paigay ako sa aking pamilya. Ako dapat ang nagaalaga sa mga ank ko hindi sila ang nagaalaga sa akin. As verbalized by the patient. J. Sexuality Reproductive Pattern Subjective data: Nung grade 6 ako nagkaroon ng menstruation. Hindi naman ako nagakakaroon ng dysmenorrhea. Mga isang linggo ako nagkakaroon. Hindi ako marunong mag breast self exam. Wala naman akong nararamadamang bukol sa aking dibdib. Hindi pa naman ako ninemenopause. Hindi ako nagpapamammogram kada-taon. As verbalized by the patient Objective data: No tenderness palpated on breasts, No masses, lesions and discharg noted. Breasts are symmetric, with brown colored areola. No inguinal adenopathy, external genitalia without erythema or lesions, vaginal mucosa pink, cervix parous, pink and without discharge. K. Value- Belief Pattern Subjective data: Christiano kami. Hindi na nga kami nakakapagsimba dahil may sakit ako. Nagdadasal na lang kami kapag may problema kami. Alam ko naman na lagging andyan ang panginoon para tulungan kami. Siya ang sandigan ko kapag hirap na hirap ako. Alam kong hinding hindi niya ako papabayaan. As verbalized by the patient Objective data: Presences of religious articles were not present such as bible and devotional books.

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IV. Physical Assessment (2/04/10) A. General Appearance PA was observed lying on her bed with her youngest brother, resting with 1 pillow on her head. The patient is oriented to time, place and person, cooperative and has a good memory both recent and remote. She is able maintain eye contact throughout the conversation. She was wearing a tidy hospital gown and is well groomed. B. Vital signs and Anthropometric Measurements (2/04/10) Temperature Pulse Rate Respiratory Rate Blood Pressure Height Weight BMI : : : : : : : 37.1 C 74 Bpm 18 Bpm 150/90 mmHg 55 ft 58 kg 22

C. Head to Toe Assessment (2/04/10) 1. Skin Brown in color, no lesions, lumps, itching or discoloration noted. Texture is smooth. Skin turgor is <2 seconds. Presence of an over-keratinized tissue about 2cmx3cm width and an ulcer of 1cmx 1cm width of granulitic tissue on the patients right foot with dressing, that is dry and intact. No pain verbalized by the patient. The patient can distinguish sharp and dull all over her body except in her right foot where she verbalized numbness on the upper part of her foot. No edema was noted. Implication: Distal symmetric neuropathy is a major risk factor for foot ulcers. people with sensory neuropathies have impairs pain sensation and are often unaware of the constant trauma to the feet caused by poorly fitting shoes, improper weight bearing, hard objects or pebbles in the shoes, or infections such as athletes foot 2. Head/ Skull 3. Hair/ Scalp 4. Face 5. Nails Skull is proportional to the size of the body, round in shape, symmetrical to all planes, no lumps upon palpation. Short thin hair, even distribution, no dandruff and spilt ends noted. Round in shape, absence of masses and lesions, no facial asymmetry There were no cyanosis, pallor and clubbing noted. Capillary refill is 3 seconds.

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6. Eyes

Eyeballs is not protruded, eye lids close symmetrically, positive blinking reflex, no discharge, conjunctiva is pink and moist, iris is brown in color , appropriate diameter of 0.5cm, sclera is white in color, pupils constrict from 4mm to 2mm, equally round and reactive to light and accommodation eyebrows are symmetrical, both parallel to the auricle of the ears. Dark circles around the eyes were noted Patient wears glasses for reading. Visual acuity is 30/20 bilaterally. Implication: Because of the patients advancing age there is hyperopic shift to farsightedness resulting from a loss of elasticity of the lens of the eye, this condition is called presbyopia. The first symptoms appear at the age of 40. Dark circles around the eyes indicates lack of sleep.

6. Ears 7. Nose 8. Mouth

Acuity good to whispered words, Tympanic membranes on good cone of light, Weber midline, AC>BC. Nasal mucosa pink, septum is midline, no sinus tenderness Oral mucosa pink, no foul odor noted, gag reflex is present, gums are pinkish, moist, no swelling, no bleeding noted, teeth are without dental carries, presence of dentures in the upper and lower incisor teeth, tongue is central in position, can distinguish different tastes, uvula is at the center, symmetrical and moves upward when the patient says ah. Trachea midline, no lesions or mass, jugular veins are not distended Axillary, cervical, submandibular and inguinal lymph nodes are not palpable. Symmetrical, oval in shape, no lesions noted, patient does not use accessory muscles for breathing. No tenderness palpated on breasts, No masses, lesions and discharge noted. Breasts are symmetric, with brown colored areola. No bulging on the surface or masses noted, bilateral, symmetrical chest expansion. Bowel sound heard 3 times per quadrant in one minute, no tenderness noted, uniformed in color, no lesions noted and no visible veins noted. Muscle strength of 4/5 on both extremities. Good Range of motion on all upper joints, no evidence of swelling or deformity, the patient can distinguish sharp from dull sensation. Biceps and triceps reflex of grade 2+. Patient has a heplock on her left hand, no redness and itching present. Implication: Because there is increased glucose production from protein and fat stores there is wasting of lean muscle mass that leads to fatigue and weakness.

8. Neck 9. Lymph Nodes 10. Chest Anterior 11. Breast 12. Chest Posterior 13. Abdomen 14. Upper Extremities

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15. Hands/Fingers 16. Genitalia 17. Lower Extremities

Complete fingers, no bruises and lesions noted. No inguinal adenopathy, external genitalia without erythema or lesions, vaginal mucosa pink, cervix parous, pink and without discharge. Muscle strength of 4/5 on both extremities. Good Range of motion on all lower extremities, no signs of swelling or edema noted. Knee Jerk reflex of 2+. Implication: Because there is increased glucose production from protein and fat stores there is wasting of lean muscle mass that leads to fatigue and weakness.

18. Feet

Presence of over-keratinized tissue about 2cmx3cm width and a ulcer of 1cmx 1cm width of granulitic tissue on the patients right foot with dressing, that is dry and intact. No pain verbalized by the patient. The patient can not distinguish sharp from dull sensation in the upper part of her sole. There are no lesions, edema, on the left foot of the patient, Patient can distinguish sharp from dull sensation on the left foot. Implication: Distal symmetric neuropathy is a major risk factor for foot ulcers. people with sensory neuropathies have impairs pain sensation and are often unaware of the constant trauma to the feet caused by poorly fitting shoes, improper weight bearing, hard objects or pebbles in the shoes, or infections such as athletes foot

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ANATOMY Anatomy and Physiology of the Pancreas Pancreas is a pinkish-grey organ situated in the upper part of ones abdomen. It is about 6 inches or 15 cms long and has a flattened bulbous head that is surrounded by part of the intestine called duodenum, a narrow body that lies behind the stomach and a tapered tail that rests on the front of the left kidney. Pancreas is one of the organs in the body that has both exocrine and endocrinal functions.

Exocrine Function: It secretes an alkaline juice with enzymes such as - amylase and lipase, which help digest the fat, protein as well as carbohydrates from the food that we eat. The alkaline juice and helps to neutralize the acid secretions of the stomach. It secretes about 1.5 liters of these juices in a day. Endocrine Function: Is made up of small clumps of cells within the pancreas, called pancreatic islets, or the islets of Langerhans. These account for only 1% of the pancreatic mass. It is composed of three distinct cell types each producing a different hormone. The two important hormones are: Glucagon is controlled by the level of blood sugar, being released when levels are too low. This greatly increases the output of sugar from the liver and returns blood sugar levels to normal. Insulin is designed to lower blood sugar levels when they become too high and is released in periods when there is a lot of sugar available, like after a meal. A lack of insulin means the body has to use fat for metabolism rather than sugar and can lead to a condition known as ketoacidosis. Insulin is a hormone produced by special cells (called beta cells) in the pancreas. Hormones are chemical messengers that circulate in the blood- sending messages to other parts of the body.

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Insulin Production After we eat- the food is digested in the stomach and the upper part of the bowel. The nutrients from the digested food are taken into the bloodstream. The carbohydrates (sugars and starches) in our food are broken down into glucose which enters the bloodstream. This glucose is used immediately for energy or can be stored in the liver or muscle as a substance called glycogen. Glucose can be released from glycogen when needed and glucose output from the liver contributes to blood glucose levels- as well as food that have just been eaten.

We need insulin to help the body use glucose from the bloodstream for energy. Glucose is the major energy source for the cells of the body- but normally glucose can only pass from the bloodstream into cells if insulin is present. If there is no insulin- blood glucose levels will be high but none of the glucose can be used for energy since it cannot enter the cells. Ketones are other substances which the body can sometimes use for energy if it cannot use glucose. In people without diabetes, ketones start to be produced from fat as an alternative energy source when supplies of glucose are becoming low- such as during fasting or illness. This can also be the case in people with diabetes- but more commonly in diabetes- production of ketones means there is a lack of insulin and the glucose that is present in the blood is unable to be used for energy.

Narrative???

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PATHOPHYSIOLOGY OF DIABETES MELLITUS

Modifiable Risk Factors: Diet: High in sugar diet Lifestyle: Lack of exercise

Non-Modifiable Risk Factors: Family History of DM (Aunt) Family History of Hypertension ()

Insulin Resistance
Diminished Intracellular reaction such as binding of insulin to receptors to initiate metabolism of glucose

Vasoconstriction Blood Pressure of: AHDL: 37 mg/dl Cholesterol: 366 mg/dl LDP: 249.2 mg/dl Triglycerides: 429 mg/dl Very low Density Lipoprotein: 2.2 mmol/l

Cell Membrane Alteration

Insulin becomes less effective at stimulating glucose uptake by tissue

Glucose (FBS): 247 mg/dl Increase glucose in blood circulation

Amlodipine 5g Pletaal 1 tab Atrovastatin 20mg Losartan 50 mg

Increased Peripheral Resistance Increased Blood pressure (Hypertension)

Sclerosis of arteries of the kidneys

Formation of abnormal glycoprotein on basement membrane of glomerolus

Sugar attracts fluid form cell of kidneys Cellular dehydration Increase urine output (Polyuria)

Formation of Polyol Pathway Glucose is shunted to this pathway and converted to sorbitol
Sorbitol interferes with nerve conduction

Decrease Blood flow to kidneys

Glucagon production

Increase Viscosity of Blood Glucose production from protein and fat stores Necrosis of Renal Parenchyma

Sluggish Blood Flow to distal parts of the body

Damage to Renal tissues

Impairs Glomerular Filtration CHON loss in urine

Nerve degeneration and delayed conduction Neuropathy

Numbness: Can not distinguish sharp from dull sensation in the upper part of her sole.

Decrease blood flow to lower extremities

Wasting of lean muscle mass Fatigue

Deceased Renal Function

Stimulates hypothalamus Excessive thirst (Polydipsia)

Decreased Erythropoietin Production Decrease sensation in Lower extremities Impaired wound Healing Infection
Presence of an overkeratinized tissue about 2cmx3cm width and an ulcer of 1cmx 1cm width of granulitic tissue on the right foot

Alteration in Erythropoiesis

Urinalysis: Protein: 3+ Glucose: 2+

Anemia
RBC: 4.29 X10^6/ul HGB: 12.2 g/dl HCT: 36%

Legend:
Signs and Symptoms Management Laboratory Results

Monocytes: 93%

Unasyn 750 mg IV

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NURSING PROBLEM LIST The nursing problems were identified through assessment by the utilization of the Gordons functional health assessment and conducting a thorough physical assessment of the patient. In prioritization of the said problems, I made use of the Maslows Hierarchy of needs and application of the ABCs (Airway-Breathing-Circulation). I have also prioritized the physical needs over psychosocial needs, and considered the urgency of each problem. Lastly, actual diagnosis was prioritized over risk diagnosis.
Nursing Diagnosis 1 Ineffective tissue perfusion: Peripheral related to impaired arterial circulation Impaired Skin Integrity related to presence of nonhealing wound on the right foot. Activity intolerance (level I) related to generalized body weakness Impaired physical mobility related to non-healing wound on the right foot Constipation related to decreased peristalsis Disturbed sleep pattern related excessive environmental stimuli (Excessive noise). Mild anxiety related to change in health status Physical problems take priority over psychological concerns. Actual diagnosis is prioritized over risk diagnosis Justification According to ABC (Airway-BreathingCirculation) circulation is the third priority in the absence of airway and breathing problems. Skin integrity is the second priority since it is the main complaint of the patient. According to Maslows hierarchy of needs, physiologic needs take precedence over safety and security, love and belongingness, self-esteem needs and self actualization needs. Physiologic needs include air, food, water, elimination, shelter, rest, sleep, activity and temperature control.

5 6

Risk for decreased cardiac output related to increased vascular resistance Risk for fall related to generalized body weakness Risk for injury related to visual impairment

10 11

NURSING CARE PLAN (DATA/ACTION/RESPONSE) Name of Patient PA Date/ Shift/ Time

February 11, 2010 6A-2P

Sex F Nursing Diagnosis

Age 48 y.o

CS M

Hospital No. 8181818

Data Action Response

D> Wala akong nararamdaman sa kanan na paa ko as verbalized by the patient - Patient cannot distinguish sharp from dull sensation in the upper part of her sole. - Hemoglobin: 12.2 g/dl Hematocrit: 36% A> Assess lower extremities - Assisted in the performance of active range of motion exercises - Encouraged ambulation - Elevated head of bed - Encouraged beep breathing exercises - Kept dressing dry and intact - Advised patient not to use lotion and powder on feet to prevent formation of moisture instead, advised patient to wash feet with mild soap and water and inspect foot daily - Health teaching about the importance of good foot care - Advised to wear thick comfortable slippers to prevent wound development - Advised patient to report immediately if there are any development of wound on feet R> Patient was able to perform deep breathing exercises -Dressing is kept dry and intact -Patient was able to verbalize importance of good foot care and inspection of foot daily.

#1 Ineffective tissue to perfusion: Peripheral related impaired arterial circulation

8:00 AM 10:00 AM

1:00 PM

2:00 PM

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Date/ Shift/ Time

February 5, 2010 6A-2P

Nursing Diagnosis #2 Impaired skin integrity related to presence of non-healing wound on the right foot.

Data Action Response

D> Presence of an over- keratinized tissue, about 2cmx3cm width with ulcer of 1cmx 1cm width of granulitic tissue on the patients right foot with dressing that is dry and intact A> Assessed status of the wound as well as the dressing from time to time - Noted changes the color, texture of the wound - Kept dressing clean and dry - Assisted in debridement by the wound care nurse - Encouraged ambulation to promote blood circulation - Washed hands before and after contact with patient to prevent further infection - Health teaching about the importance of early detection of skin changes , how to properly take care of the wound and importance of hand washing to prevent further infection. - Teach client and family of proper foot hygiene - Administered Unasyn 750 mg IV every 8 hours R> Dressing is kept dry and intact - Patient verbalized importance of early detection of skin changes, importance of taking care of the wound and importance of hand washing to prevent further infection . - No signs of further infection were noted.

8:00 AM

10:00 AM

1:00 PM

2:00 PM

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Date/ Shift/ Time

February 6, 2010 6A-2P

Nursing Diagnosis #3 Activity intolerance (Level I) related to generalized body weakness

Data Action Response

D> Madali ako manghina kapag mataas ang presyon ko, kapag mataas ang aking presyon ay nahihilo ako kaya nagpapahinga na lamang ako. As verbalized by the patient - Patient appears weak. - Muscle strength of 4/5 on both lower and upper extremities - BP of 150/90mmHg A> Assess factors contributing to weakness - Monitored vital signs and watched out for significant sudden changes - Placed call bell and personal necessities within reach - Instructed and assisted to rise gradually - Provided periods of rest between activities - Asked watcher to be with the patient at all times - Assisted in ambulation - Encouraged energy conserving techniques such as sitting while brushing her teeth or combing and carrying out activities in a slower pace - Encouraged gradual progression of activities R> BP of 150/90 mmHg - Watcher was with the patient throughout the shift - Patient was able to have rest periods and was able to do energy saving activities

8:00 AM 9:00 AM

11:00 AM

2:00 PM

Date/ Shift/ Time

February 7, 2010 6A-2P

Nursing Diagnosis #4 Impaired physical mobility related to

Data Action Response

D> Nung nagkasugat ako ay hirap akong ang maglakad dahil iniiwasan kong malagyan ng

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presence of non healing wound on the right foot

8:00 AM

11:00 PM

2:00 PM

dumi aking sugat As verbalized by the patient. - Presence of an over- keratinized tissue, about 2cmx3cm width with ulcer of 1cmx 1cm width of granulitic tissue on the patients right foot with dressing that is dry and intact A> Assessed degree of immobility produced by the injury - Asked watcher to assist patient during ambulation - Instructed patient as well as the watcher to use side rails in changing position - Instructed patient to do passive exercises to increase blood flow - Raised side rails to ensure safety - Encouraged rest periods to reduce fatigue - Encouraged to always keep dressing clean and dry to promote proper wound healing R> Patient was able to ambulate with assistance from watcher - Patient was able to do passive exercises - Patient was able to use side rails during ambulation

Date/ Shift/ Time

February 8, 2010 6A-2P

Nursing Diagnosis Data Action Response #5 Constipation related toD>D> Hindi ako mashado nakakadumi dito, hindi ko alam kung bakit pero hindi pa ako dumudumi decreased peristalsis
simula ng dumating ako., madalas nakahiga ako dito. As verbalized by the patient.

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7:00 AM 8:00 AM

9:30 AM

1:00 PM 2:00 AM

- Patient has no bowel for4 days - Bowel sound heard 3 times per quadrant in one minute A> Assessed usual elimination habits - Assessed bowel sounds - Encouraged patient to increase oral fluid intake (1.5-2 liters a day) - Encouraged ambulation - Encouraged passive exercises to stimulate peristalsis - Encouraged to eat high fiber food - Assisted client in going to the bathroom - Provided privacy for defecation R> The patient was able to defecate

CONCLUSION
Diabetes is a very serious condition that can become life threatening and cause many difficult effects on the body. Many people who develop diabetes suffer from serious circulatory problems that sometimes result in the loss of one or more limbs. Diabetes prevention is very important because of the seriousness of this condition. Some people have a genetic predisposition to this condition, and those people who have a family history of diabetes should be particularly intent on diabetes prevention. At the end of the Nursing Care Plan I was able to compose a holistic nursing care plan for the patient. I was also able to involve the patient in the management of her condition by teaching her the

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proper dressing of her wound, importance of foot care, daily inspection of her feet and the importance of hand washing. I have also formulated 10 patient specific nursing problems namely: 1. Ineffective tissue perfusion: Peripheral related to impaired arterial circulation 2. Impaired Skin Integrity related to presence of non-healing wound on the right foot. 3. Activity intolerance (level I) related to generalized body weakness 4. Impaired physical mobility related to non-healing wound on the right foot 5. Constipation related to decreased peristalsis 6. Disturbed sleep pattern related excessive environmental stimuli (Excessive noise). 7. Mild anxiety related to change in health status 8. Risk for decreased cardiac output related to increased vascular resistance 9. Risk for fall related to generalized body weakness 10. Risk for injury related to visual impairment I have prioritized each problem by utilization of the Maslows Hierarchy of needs and application of the ABCs (Airway-Breathing-Circulation). I have also prioritized the physical needs over psychosocial needs, and considered the urgency of each problem. Lastly, actual diagnosis was prioritized over risk diagnosis. I have also formulated 5 patient centered nursing care plans using the DAR (Data/Action/Response) format. At the end of the Nursing Care Plan, the patient was able to understand the importance of complying with the management of her condition and was able to participate in the management of her condition. This is very important so the patient will know the seriousness of her case so that she will take the initiative to step up and do something about her condition such as complying with her medications, exercising and conform to her diet. At the end of the Nursing Care Plan, the IANAHP was able to assess the level of knowledge of the trainee regarding the nursing care plan of her case and evaluate the competency of the trainee on how she understands the nursing care plans of her patients case. With all of this at hand, I have successfully met all the objectives set for the patient, the IANAHP and the trainee. Health care providers especially nurses, should take the responsibility to recognize and identify patients needs and patients who are at risk of developing complications, that is why it is very important to have proper assessment and to continually evaluate and assess the patient while they are in our care. It is also very important that healthcare providers has a understanding on the progress of their patients condition, it is key to learning how to identify and give the proper management to the patient, it will also help the healthcare provider to gain additional knowledge and skills in the course of their work.

BIBLIOGRAPHY

Brunner & Suddarths Medical- Surgical Nursing, 11th Edition Copyright 2004. Essentials of Pathophysiology Concepts of Altered Health States, Carol Mattson Porth, 2Nd Edition Copyright 2007 Fundamentals of Nursing Concepts, Process and Practice, Kozier, Erb et. Al, 7th Edition Fundamentals of Nursing, Potter & Perry, 5th Edition

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Bates Pocket Guide to Physical Assessment and History Taking, 4th Edition, Bickley. Nursing diagnosis Handbook, A Guide to Planning Care, Mosby, 7th Edition.

APPENDIX
LABORATORY RESULTS (1/21/10) URINE ANALYSIS (1/21/10) Normal Color Amber Clarity Clear Specific Gravity 1.010-1.025 Result Yellow Clear 1.020

*Reference: Fundamentals of Nursing Concepts, Process and Practice, Kozier, Erb et. Al, 7th Edition

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CHEMICAL ANALYSIS (1/21/10) Normal Result PH 7.35-7.45 6.5 Protein Not present 3+ Glucose Not present 2+ Blood Not present 1+ Ketone Not present (-) Nitrite Not present (-) Bilirubin Not present (-) Urobilinogen Not present 0.2EU/dl
*Reference: Fundamentals of Nursing Concepts, Process and Practice, Kozier, Erb et. Al, 7th Edition

URINE FLOWCYTOMETRY (1/21/10) Unit Normal WBC /hpf 0-3 /ul 0-17 RBC /hpf 0-2 /ul 0-11 Epithelial Cells /hpf 0-3 /ul 0-17 Hyline Cast /hpf 0-3 /ul 0-1 Bacteria /hpf 0-50 /ul 0-278

Result 1 5 2 13 2 13 1 2 15 82

WBC Neutrophil Lymphocytes Monocytes Eosinophils Basophils RBC HGB HCT MCV MCH MCHC RDW RBC Dist. Width

CBC (1/21/10) Unit Normal 10^3/ul 4.5-11 % 50-70 % 20-40 % 2-8 % 2-8 % 0-1 X10^6/ul g/dl % fL Pg g/l % 4.2-5.4 12-16 38-47 80-100 27-32 31-35 11.6-13.7

Result 2.51 63.9 24 93 2.4 0.4 4.29 12.2 36 83.9 28.4 33.9 13.8

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PIT MDV

X10^3/ul fl

150-400 7.8-11

471 10 Result 37 366 249.2 429 2.2 21 1 247 4.3 5.5

AHDL Cholesterol LDP Triglycerides Very low Density Lipoprotein BUN Creatinine Glucose (FBS) Potassium Uric Acid

LIPID PROFILE (1/21/10) Unit Normal mg/dl >65 mg/dl <200 mg/dl <100 mg/dl <200 mmol/L <1.0 mg/dl mg/dl mg/dl mmol/dl mg/dl 6-20 0.5-1.3 70-115 3.5-5 <5.7

Legend: Black: Normal Value Red: Above normal values Blue: Below normal Values

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